What are the causes of migratory polyarthralgia?

Causes of Migratory Polyarthralgia

The five most important causes of migratory polyarthralgia are: (1) Acute Rheumatic Fever, (2) Viral infections (particularly parvovirus B19, arboviral infections like chikungunya, and Lyme disease), (3) Gonococcal arthritis, (4) Reactive arthropathies, and (5) Drug-induced syndromes (particularly antithyroid medications).

1. Acute Rheumatic Fever (ARF)

ARF is the classic cause of migratory polyarthritis, particularly in moderate-to-high risk populations following group A β-hemolytic streptococcal infection 1.

• The migratory pattern is characteristic: pain and swelling move from one joint to another, with previous joints improving as new joints become affected 2
• Predominantly affects large joints (knees, ankles, elbows, wrists) 2
• Shows dramatic response to salicylates or NSAIDs within 24-48 hours 1, 2
• Self-limited course lasting approximately 4 weeks even without therapy 2
• Critical pitfall: Early use of over-the-counter NSAIDs may mask the classic migratory pattern, making diagnosis more difficult 1
• Must exclude other manifestations including carditis, chorea, erythema marginatum, and subcutaneous nodules 2

2. Viral Infections

Parvovirus B19

Parvovirus B19 causes acute symmetric polyarthritis in adults, but can present with migratory arthritis in approximately 40% of cases 3.

• Most commonly affects metacarpophalangeal joints, proximal interphalangeal joints, wrists, and knees 3
• 75% of patients have close contact with children, with 58% exposed to children with clinical parvovirus 3
• Viral prodrome occurs in 63% of cases, though the typical "slapped cheek" rash is uncommon in adults 3
• Most cases resolve within 6 weeks, though 19% may have symptoms lasting longer than 6 months 3

Arboviral Infections (Chikungunya, Dengue)

Multiple severe arthralgia is a hallmark symptom of arboviral infections, particularly chikungunya 4.

• Consider in patients with travel history to tropical or endemic regions 4, 5
• Presents with systemic febrile illness and severe polyarthralgia/arthritis 4
• Chikungunya often presents with characteristic rash 4

Lyme Disease

Lyme disease causes migratory joint pain and swelling, often preceded by erythema migrans rash in 60-80% of cases 2.

• History of tick exposure in endemic areas is common 2
• Joint symptoms range from arthralgias to brief attacks of arthritis to chronic erosive synovitis 6
• About 60% of untreated patients develop brief attacks of oligoarticular arthritis 2 weeks to 2 years after disease onset, primarily affecting large joints, especially the knee 6

Other Viral Causes

• Mumps arthritis presents with migratory polyarthritis that may run a protracted course, typically occurring 1-2 weeks after complete clearing of parotitis 7
• Coxsackievirus and adenovirus can cause persistent and/or recurrent polyarthritis 7

3. Gonococcal (Disseminated Gonococcal Infection)

Gonococcal arthritis is a critical diagnosis to exclude, as it requires urgent treatment and can mimic other causes of migratory polyarthralgia 3.

• Two patients in a parvovirus outbreak were initially presumed to have gonococcal arthritis before viral titers were available 3
• Requires urgent arthrocentesis if suspected, with high index of suspicion in patients with severe joint pain and swelling 5
• Must be excluded as part of the differential diagnosis for septic arthritis 1

4. Reactive Arthropathies

Post-streptococcal reactive arthritis and other reactive arthropathies can present with migratory joint symptoms but may not fulfill all Jones criteria for ARF 2.

• The American Heart Association emphasizes careful exclusion of autoimmune, viral, or reactive arthropathies when evaluating polyarthralgia 1
• Familial Mediterranean Fever can present with recurrent migratory polyarthritis, though this is an atypical presentation 8
• Reiter's syndrome or reactive arthritis is most similar to Lyme arthritis in adults 6

5. Drug-Induced Syndromes

Antithyroid arthritis syndrome (AAS) from medications like methimazole causes fever, rash, myalgia, and migratory polyarthralgia 9.

• Characterized by systemic migratory pain in muscles and joints following antithyroid drug initiation 9
• Mimics rheumatic disorders, complicating diagnosis 9
• Temporal association with medication is key to diagnosis 9
• High cross-sensitivity between antithyroid drugs limits pharmacological alternatives 9

Critical Diagnostic Approach

When evaluating migratory polyarthralgia, systematically exclude septic arthritis first, then assess for ARF in appropriate populations, followed by viral etiologies based on exposure history 1, 5.

• Document symptom onset, duration, and migratory versus persistent pattern 5
• Examine all peripheral joints for tenderness, swelling, erythema, warmth, and range of motion 5
• Obtain inflammatory markers (ESR, CRP), though normal values do not exclude inflammatory disease 5
• Screen for recent infections, travel history to endemic areas, medication use, and tick exposure 4, 5, 2
• Key pitfall: Polyarthralgia is highly nonspecific and almost always represents an illness other than ARF in low-risk populations 1